What’s Next After Obamacare?

Trumpcare’s success depends on a pivot toward value-based care

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It has been interesting reading reputable medical journals such as the New England Journal of Medicine and the prognostications about the end of the Affordable Care Act. Obamacare is all about access, quality, and affordability. These are all worthy goals for any health policy maker—including Tom Price, who is likely to be confirmed as the new secretary of Health and Human Services, and others who will join the Trump administration. There are several initiatives under Obamacare that have proven to be quite popular including increased coverage under Medicaid, ensuring those with pre-existing conditions are not discriminated against, and allowing children to stay on their parents’ health plans until age 26. Based on their popularity, they are likely to become part of Trumpcare. The main problem with these initiatives, however, is that they increase costs under a mainly fee-for-service system.

Another issue not mentioned often in the transition to Trumpcare is how services will be paid for. This is a matching of the costs with the outcomes; in other words, value. This matter goes to the heart of whether we can afford healthcare in the future, considering healthcare is fast approaching 20 percent of the U.S. GDP. Improvements in access will likely not be entirely successful until the U.S. pivots towards value-based care.

So what is value based care? In its most ideal form, it translates into services being provided at lower costs and better outcomes (e.g. lower mortality, lower morbidity, improved quality of life for patients) than what exists today. However, also acceptable will be lower-cost services for a similar outcome and same-cost services for better outcomes. It may even mean higher-cost services that provide extremely good outcomes, such as extending lives for long periods with excellent quality of life. These all need to be evaluated and provided to decision makers—i.e. payers and providers and to patients—in order for good decisions to be made. As well, payers such as Medicare will likely need to embrace this cost/outcome equation. (Currently by law Medicare can only consider outcomes. This may change.) These types of analyses and coverage determinations need to be baked into our reimbursement system if we are going to start obtaining value for money spent.

In the end Trumpcare is likely to incorporate a number of the positive attributes of Obamacare as outlined above. The question is, will Trumpcare embrace value analysis? My guess is that Trump, being a capitalist, will embrace principles which hinge on competition, open markets, profits, and the flow of information (i.e. value analysis), which in turn will guide consumer choices. Value analysis should be a big part of Trumpcare. Here’s hoping this is the case.